Ovarian Tumors Flashcards
Concerning characteristics of a pelvic mass
Worry about pelvic mass if >8cm, solid or cystic+solid, nodular, multilocular, + doppler flow, bilateral
3 categories of ovarian tumors
Epithelial, germ cell, or stroma.
Metastatic ovarian tumors
Usually GI tract (Krukenberg), breast, endometrium
Usually spreads via direct exfoliation; can be lymphatic too, more rarely hematogenous
Epithelial tumors (65-70%)
20+ years (esp older)
Serous cystadenocarcinoma, mucinous, endometriod, clear cell, Brenner, undifferentiated
Germ cell tumors (15-20%)
0-25+ years
Teratoma, dysgerminoma, endodermalsinus tumor, choriocarcinoma,embryonal carcinoma
Sex cord stromal (5-10%)
All ages
Granulosa-theca cell tumors, Sertoli-Leydig cell tumors, fibromas
What is the most common ovarian tumor?
Epithelial is #1 most common
Etiology of epithelial ovarian tumor
Thought to be 2/2 chronic uninterrupted ovulation → malignant transformation
Risk factors for epithelial ovarian tumor
Early menarche, infertility, late menopause, nulliparity, delayed childbearing, increasing age
10-15% have familial syndrome (e.g. BRCA 1>2 or HNPCC)
Protective factors for epithelial ovarian tumor
OCPs are protrective (50% if on OCP x 5yrs), also tubal ligation / hysterectomy
Symptoms of epithelial ovarian tumor
Asx or vague, nonspecific complaints (lower abd pain, bloating, distention, early satiety, other GI sx, urinary frequency / dysuria / pelvic pressure when more advanced, ascites if later)
Physical exam findings of epithelial ovarian tumor
Fixed, solid, irregular pelvic mass +/- ascites.
Epithelial ovarian tumor met to umbilicus
Sister Mary Joseph nodule
Diagnosis of epithelial ovarian tumor
Pelvic U/S; CT/MRI can be helpful too, then look for mets / other primaries (barium enema, IVP, etc)
Get a CA-125.
If wondering about other types of tumors, alpha-fetoprotein, LDH, hCG too.
Staging of epithelial ovarian tumor
Surgical (TAHBSO, omentectomy, peritoneal washings, Pap smear of diaphragm, sampling of pelvic / periarotic lymph nodes).
Many present in stage III/IV (2/2 vague symptoms) and 5-yr survival low.
Goal is optimal debulking (no tumor > 1cm left behind)
Treatment of epithelial ovarian tumor
Usually do adjuvant carboplatin + paclitaxel
If optimal debulking achieved, can do intraperitoneal chemo if tolerated
CA-125 elevated in 80% epithelial tumors - not for screening, but to track tx /recurrence
Can also get CT scans to follow serially
Most common type of epithelial ovarian tumor
Most common type: serous cystadenocarcinoma, but types can vary from borderline to high malignancy
Germ Cell ovarian tumor
Most grow rapidly, limited to one ovary, stage I at time of diagnosis, curable!
95% benign
Symptoms of germ cell ovarian tumor
Capsule distention → pain, hemorrhage, necrosis → acute pelvic pain; can also torse / rupture
Dysgerminoma
No differentiation (totipotent) Most common malignant germ cell tumor Uniquely radiosensitive! but still do chemo (better fertility) LDH= tumor marker
Embryonalcarcinoma
Starting to differentiate towards:
Endodermal sinus tumor
Choriocarcinoma
Teratoma
Endodermal sinus tumor
Differentiation: Extraembryonic (yolk sac)
AFP = tumor marker
Choriocarcinoma
Differentiation: Trophoblastic (placental)
hCG = tumor marker
Teratoma
Differentiation: Embryonic (fetal)
Benign cystic mature teratoma = dermoid cyst = most common germ cell tumor!
Cystic, has skin / hair / teeth /etc
Do a cystectomy for definitive dx & to r/o malignancy!
Immature teratoma = malignant version
Treatment for benign germ cell ovarian tumors
For benign tumors (mature teratomas) → cystectomy or oophorectomy
Treatment for malignant germ cell ovarian tumors
For malignant tumors, unilateral salpingo-oophorectomy if fertility desired, or TAH/BSO
Everything except stage IA dysgerminomas / immature teratomas gets multiagent chemo
Usually BEP = bleomycin, etoposide, cisplatin=Platinol
Can follow response with tumor markers
Dysgerminomas are uniquely radiosensitive - but often still do combo chemo to protect fertility
Sex cord-stromal tumors
Generally low grade, don’t recur, usually unilateral
Treatment with unilateral sapingooophorectomy
No role for chemo or radiation in these tumors
Granulosa-Theca cell tumors
Are #1 (70%)
Can happen at any age
Functional: can make lots of estrogens → endometrial hyperplasia, cancer 2/2 stimulation!
See Call-Exner bodies (pathognomonic) - with grooved “coffee-bean nuclei”
Symptoms of Granulosa-Theca cell tumors
Can cause precocious puberty, feminization, menstrual irreg, secondary amenorrhea, postnemopausal bleeding 2/2 high estrogen
Diagnosis of Granulosa-Theca cell tumors
High estradiol, inhibin A/B
Sertoli-Leydig cell tumors
Are more rare
Mostly in women < 40
Like the ovary grew a little pair of testicles: making androgens
Sx: see virilizing effects (breast atrophy, hirsutism, deepend voice, etc) + oligo / amenorrhea.
Ovarian fibroma
Derived from mature fibroblasts, not functional
Can be a/w ascites: tumor + ascites + right hydrothorax = Meigs syndrome
Fallopian tube cancers
Really rare, usually adenocarcinoma,
Behave like ovarian cancer (peritoneal spread, ascites)
More frequently in caucasians, BRCA ½, nullips, infertility
Symptoms of fallopian tube cancers
Usually asymptomatic
Classic = “Latzko’s triad”, profuse watery discharge + pelvic pain + pelvic mass but only in 15%
Hydrops tubae profluens (intermittent hydrosalpinx) = spontaneous or pressure-induced watery / blood tinged vaginal discharge that makes abdominal mass shrink
Work up of fallopian tube cancer
Pelvic U/S, CA-125 can be up, cervical cytology rarely shows malignancy
Usually dx @ surgery (since so rare); stage surgically
Treatment of fallopian tube cancer
Treat like epithelial ovarian carcinoma (TAHBSO, omentectomy, cytoreduction, peritoneal sampling, LN sampling, etc) and then carboplatin + paclitaxil
